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OKLAHOMA STATE FAIR® September 13-23, 2011 Oklahoma State Fair Horse Show Division PO Box 74943 - Oklahoma City OK 73147 Telephone: (405) 948-6735 or e-mail mpankow@okstatefair.com

EQUINE VETERINARY CANCELLATION FORM

Must be original form, completed in ink or typed, completely legible and containing original signatures of recorded owner (or) responsible trainer/agent AND attending veterinarian(s). It MUST be received (mailed or presented in person) in original form {i.e. copies not acceptable} to OSF Horse Show Office no later than 6:00 p.m. on the day preceding the first intended/originally entered class for the horse noted below. Completion of this form does not guarantee refund. OSF Management/Staff will review documentation and information. Exhibitor/owner will be notified of decision within 60 days after completion of 2012 Oklahoma State Fair. Registered name of horse: ___________________________________________________________________________ Breed Registry: ____________________________________________Registry#:________________________________ Recorded owner:___________________________________________________________________________________ Owner’s Address: _________________________________________________________________________________ Owner’s City, State Zip:______________________________________________________________________________ Owner’s telephone numbers:__________________________________________________________________________ Owner’s e-mail address:_____________________________________________________________________________ Owner’s signature: _________________________________________________________________________________ Trainer/Agent Name:________________________________________________________________________________ Trainer/Agent Address:______________________________________________________________________________ Trainer/Agent City, State Zip:_________________________________________________________________________ Trainer/Agent’s telephone numbers:____________________________________________________________________ Trainer/Agent’s e-mail address:________________________________________________________________________ Responsible trainer/agent’s signature: __________________________________________________________________ The following section of the form must be completed in entirety by the attending veterinarian/veterinary hospital and must be legible and concise: Description of horse: Gender________Color_________D.o.B.:_____________ General description of markings:________________________________________________________________________________________________ _________________________________________________________________________________________ Nature/description of injury or illness causing withdrawal of this horse from competition at Oklahoma State Fair: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Date of occurrence of injury or initial onset of illness:___________________________________________________ Provide and attach supplementary list showing specific dates of examination and treatment: include name of each veterinarian and all prescribed treatments, medications and prognosis at each time. On this list, provide legible address and telephone number of each/all attending veterinarian(s). Provide actual and original SIGNATURE(s) below, of each/all attending veterinarian(s) as noted above/per attached. Signature(s) indicates the specific and detailed treatment as described above/per attached, as performed by each licensed veterinarian and the testimony that this animal is being withdrawn from competition based on the information provided herein and to be the qualified and true opinion by the attending veterinarian(s) that this animal is unable to compete in the Oklahoma State Fair, September 13-23, 2012. Signature on this form constitutes agreement to be contacted, if deemed necessary by the management of the Oklahoma State Fair for additional information/documentation/verification. Signature:_____________________________________________________________Date:___________________ (primary attending veterinarian) Signature:_____________________________________________________________Date:___________________ Signature:_____________________________________________________________Date:___________________

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2012 Oklahoma State Fair Equine Veterinary Cancellation Form


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